Pennsylvania Guidelines for Management of Food Allergies in Schools - Recommendations & Resource Guide for School Personnel

 
Pennsylvania Guidelines for Management of Food Allergies in Schools - Recommendations & Resource Guide for School Personnel
Pennsylvania Guidelines for
Management of Food Allergies
         in Schools
 Recommendations & Resource Guide for
         School Personnel

                 2011
Table of Contents

Acknowledgements............................................................................................................ 3

Introduction ....................................................................................................................... 5

SECTION 1: UNDERSTANDING THE DISEASE
     Food Allergies on the Rise ............................................................................................ 7
     Allergic Reaction Characteristics ................................................................................. 7
     Anaphylaxis .................................................................................................................. 8
     Effective Food Allergy Management ............................................................................ 8

SECTION 2: ADDRESSING STUDENT NEEDS
     Actions and Considerations for Administrators on Development of School Policy... 14
     Actions for Developing Training for School Staff ...................................................... 17
     Actions for Principals.................................................................................................. 18
     Actions for School Nurses .......................................................................................... 19
     Actions for Teachers ................................................................................................... 22
     Actions for Counselors................................................................................................ 24
     Actions for Custodians ................................................................................................ 25
     Actions for Coaches & Physical Education Instructors .............................................. 26
     Actions for Food Service Managers & Lunchroom Staff ........................................... 27
     Actions for Bus Drivers .............................................................................................. 29
     Actions for Parents / Guardians .................................................................................. 30
     Actions for Students with Food Allergies ................................................................... 32

SECTION 3: TOOLS FOR EFFECTIVE FOOD ALLERGY MANAGEMENT IN SCHOOLS
     Dietary Accommodations Instructions and Form ....................................................... 34
     Sample Emergency Care Plan Template (ECP) .......................................................... 38
     Sample Individualized Healthcare Plan (IHP) ........................................................... 39
     Sample 504 for Student with Food Allergies .............................................................. 40
     Sample Individualized Transportation Plan (ITP) ...................................................... 45

SECTION 4: SCHOOL RESPONSIBILITIES UNDER LAW
     Federal Laws ............................................................................................................... 49
                                                                              1
State Laws & Regulations ........................................................................................... 52

APPENDICES
  A. Glossary of Terms .................................................................................................. 55
  B. Resource List .......................................................................................................... 57
  C. Cleaning Research .................................................................................................. 64
  D. Excerpts from Guidelines for Pennsylvania Schools in Administration of
      Medications and Emergency Care ......................................................................... 65
  E. Sample Parent Permission and Licensed Prescriber Medication Order ................. 67
  F. Sample Letters ........................................................................................................ 68
  G. Excerpts from Civil Immunity Law ....................................................................... 70
  H. Excerpt from Pennsylvania Public School Code of 1949 ...................................... 72

                                                                         2
Acknowledgements

  These Guidelines contain excerpts from the Massachusetts and Illinois Guidelines for Managing Life
  Threatening Food Allergies in Schools. A special thank you to those States for allowing us to use and
                                 adapt language from their Guidelines

A special thank you is also extended to the following individuals and organizations (stakeholder group)
for their valuable contributions to the Resource Guide:

Pennsylvania State Agencies:                    Tracy B. Fausnight, M.D.
                                                Pediatric Allergy Specialist
Cheryl Oberholser MS, RN, LDN                   Penn State Hershey Medical Center
Public Health Nutrition Consultant
Division of Food and Nutrition                  Ann Gottlieb
Pennsylvania Department of Education            Parent Volunteer- Education/Awareness
                                                Coordinator, Penn State Hershey Food
Beth Anne Bahn RN, MSN, CSN                     Allergy Support Group
Director
Division of School Health                       Ms. Hoover-Vogel
Pennsylvania Department of Health               Legislative and Research Coordinator
                                                Pennsylvania Association of School
Vonda Fekete MS, RD                             Business Officials
State Director, Child Nutrition Programs
Division of Food and Nutrition                  Dana Kasner RN, BSN
Pennsylvania Department of Education            Parent from Centennial School District

Dianne Dabulis RD, MPA, LDN                     Kathy Halkins BSN, CSN, Med
School Nutrition Program Supervisor             Past President
Division of Food and Nutrition                  Pennsylvania Association of School Nurses and
Pennsylvania Department of Education            Practitioners

Jean Inskip                                     Lynda Mitchell
Bureau of Special Education                     President
Pennsylvania Department of Education            Kids With Food Allergies Foundation

                                                Randi Mongiello RN, LDN
Pennsylvania Community Partners:                Assistant Director of Nutritional Services
                                                Lower Merion School District
Gina Clowes
Allergymoms.com                                 Terry Quinlan MA, RN, CSN
                                                Supervisor School Health Services
Kristin Ehrhart                                 Lower Merion School District
Policy Specialist
Pennsylvania School Boards Association

                                                   3
Davelyn Smeltzer                         Christopher Weiss
Director, Policy Services                Vice President, Advocacy and Government
Pennsylvania School Boards Association   Relations
                                         The Food Allergy & Anaphylaxis Network
                                         (FAAN)

                                            4
Introduction
PURPOSE OF THIS GUIDE
Act 104 of 2010 charged the Pennsylvania Department of Education (PDE) and the Pennsylvania
Department of Health (DOH) with developing state guidelines for managing life threatening food
allergies in schools. It is imperative that the parents/guardians, student, school nurse, school nutrition
services director, and other school staff work together and coordinate their efforts to provide a safe
learning environment for students with life threatening food allergies. School nutrition service and school
nurses must follow pertinent federal and state laws and regulations in regards to serving appropriate
meals, administering medication, and developing medical plans of care for students with food allergies.
Furthermore, school policies and procedures must be consistent with state laws and regulations and with
the standards of nursing and medical practice.

ORGANIZATION OF THIS GUIDE
This guide is organized into four major sections so that the diverse group of intended users can easily
access information and tools relevant to their needs and roles:

SECTION 1: UNDERSTANDING THE DISEASE
The first section of this guide provides national statistics, characteristics of an allergic reaction and
anaphylaxis, and describes effective food allergy management practices.

SECTION 2: ADDRESSING STUDENT NEEDS
Section 2 presents food allergy management roles and responsibilities for school personnel,
parent/guardian, and student, as well as guidance on training of school staff and development of policies.
The school personnel section includes separate action sheets for:
    • Principals
    • School Nurses
    • Teachers
    • Counselors
    • Coaches & Physical Education Instructors
    • Food Service Managers & Lunchroom Staff
    • Custodians
    • Bus Drivers
    • Parents/Guardians
    • Students with Food Allergies

SECTION 3: TOOLS FOR EFFECTIVE FOOD ALLERGY MANAGEMENT IN SCHOOLS
This section includes useful samples of key tools for effectively managing food allergies in schools:

   Dietary Accommodations Instructions and Form
   Sample Emergency Care Plan Template
   Sample Individualized Healthcare Plan
   Sample 504 for Student with Food Allergies

SECTION 4: SCHOOL RESPONSIBILITES UNDER LAW
                                                       5
There are federal and state laws that address schools’ responsibilities to students with food allergies.
These laws are outlined in Section 4 of this guide.

APPENDICES are included to provide a useful glossary of key terms and a list of credible resources.

                                                   6
Section 1. Understanding the Disease
FOOD ALLERGIES ON THE RISE
Approximately 4% of school-aged children have food allergies (about 2.2 million in the US), and it is
generally believed that the prevalence of food allergy among children is increasing. One study showed
that peanut and tree nut allergy tripled among children from 1997 to 2008, and the CDC recently reported
that food allergy among children increased 18% from 1997 to 2007.

ALLERGIC REACTION CHARACTERISTICS
                                                                                                              .
Allergic reactions to foods vary and can range from mild to severe, life- threatening reactions. Every food
allergic reaction has the possibility of developing into a life-threatening reaction and even with proper
treatment can be fatal. A life-threatening reaction can occur within minutes or hours after exposure to the
allergen. Besides food, bee/insect stings, as well as medications and latex, also have the potential of
causing life-threatening reactions.

The following eight foods cause 90% of the allergic reactions in the United States:

Eggs                                              Soy
Fish (haddock, tuna, salmon, etc.)                Shellfish (shrimp, crab, lobster, etc.)
Milk                                              Tree Nuts (Brazil nuts, hazelnut, walnut, etc.)
Peanuts                                           Wheat

During an allergic reaction to a specific food, the immune system recognizes a specific food protein as a
target. This initiates a sequence of events in the cells of the immune system resulting in the release of
chemicals, such as histamine. Ingestion of the food allergen is the principal route of exposure leading to
allergic reaction. The symptoms of a food-allergic reaction are specific to each individual. Even a trace
amount of food can, in some instances, quickly lead to fatal reactions.

Research indicates that exposure to food allergens by touch or inhalation is unlikely to cause a life-
threatening reaction. However, if children touch the allergen and then place their fingers in or near their
nose or mouth, the allergen could become ingested and could cause a life-threatening reaction.

Allergies can affect almost any part of the body and cause various symptoms. The most dangerous
symptoms of anaphylaxis include, but are not limited to, breathing difficulties, a drop in blood pressure,
or shock, which are potentially fatal. Common signs and symptoms of allergic/anaphylactic reactions may
include:

Change of voice/hoarseness                        Itching (of any part of body)
Coughing                                          Itchy, scratchy lips, tongue, mouth, and/or throat
Cyanotic (bluish) lips and mouth area             Nausea/vomiting
Diarrhea                                          Red, watery eyes
Difficulty breathing/shortness of breath          Runny nose
Difficulty swallowing                             Sense of doom
Dizziness/change in mental status                 Stomach cramps/abdominal pain
Fainting or loss of consciousness                 Swelling (of any part of body)
Flushed, pale skin                                Throat tightness or closing
Hives/rash (of any part of body)                  Wheezing
                                                      7
ANAPHYLAXIS
When the symptoms are rapid in onset and severe, the medical diagnosis is anaphylaxis. With anaphylaxis
there is always the risk of death. Death could be immediate or may happen two to four hours later due to a
late phase reaction. The most dangerous symptoms include breathing difficulties and a drop in blood
pressure leading to shock.

The treatment for anaphylaxis is prompt administration of epinephrine, transport by emergency medical
services (EMS) to the nearest hospital emergency department, even if symptoms have been resolved, and
followed by an observation period of four hours. A single dose from an epinephrine auto-injector may
provide a 10-15 minute (or less) window of relief. A second dose of epinephrine may be required if
symptoms do not lessen or if medical help does not arrive quickly.

EFFECTIVE FOOD ALLERGY MANAGEMENT
                     The goal of effective food allergy management is to reduce and/or
                     eliminate potential reactions. The keys to meeting this goal are prevention,
                     education, awareness, communication, and emergency response.

                      Adults responsible for students with food allergies must be familiar with each
                      student’s individual medical plan of care. These plans contain the specific actions
                      necessary to keep the student safe. All complaints from students with a food allergy
are to be taken seriously.

There are some general considerations for students with food allergies:
   • Remember students with food allergies are children/teens, first and foremost. Do not ask them if it
       is acceptable to deviate from any of their individual plans. Be aware of signs of anxiety or
       bullying.
   • Also, younger students are more likely to put their hands/items in their mouths and may require
       food-free or allergen-free classrooms. This may include everyone thoroughly cleaning their hands
       before entering the classroom and after eating.
   • Accidents are more likely to happen when there is an unplanned event, such as an unplanned
       celebration or an off-premises event like a field trip with food. It is essential that the student’s
       medical plans of care are followed exactly. If a staff member has any questions, he or she should
       ask the school nurse before allowing any changes. This also applies to changes that may not
       directly involve eating.

ELEMENTS OF EFFECTIVE FOOD ALLERGY MANAGEMENT IN SCHOOLS
Students with food allergies need supportive environments to help them take care of their food allergy
throughout the school day and at school functions. There are several key elements of effective food
allergy management in school, including:

    •   Developing and implementing written medical plans of care that outline each student’s food
        allergy management
    •   Following an individualized meal plan
    •   Planning for special school events
    •   Planning for disasters and emergencies
    •   Dealing with emotional and social issues

                                                     8
Each of these elements of effective food allergy management in schools is explored in more detail in the
remainder of this section.

  Written Medical
   Plans of Care

Students with food allergies are more likely to succeed in school when parents/guardians, school
personnel, and healthcare providers work collaboratively to ensure effective food allergy management.
Prior to entry into school or for a student who is already in school, immediately after the diagnosis of a
food allergy, the parent/guardian should meet with the school nurse assigned to the student’s building to
develop the appropriate medical plans of care: Emergency Care Plan (ECP) (also interchangeable with
Food Allergy Action Plan, FAAP), Individualized Health Care Plan (IHP), 504 Service Plan, and
Individualized Education Program (IEP) with a medical component.

The school nurse, collaborating with the building principal, nutrition service director, school physician,
and parent/guardian, shall determine the best way to promote a multi-disciplinary approach to plan for the
care of the student with a food allergy.

In addition, the team may include but is not limited to:
   •   Administrative representative
   •   Nutrition service staff
   •   Teachers and specialists (e.g.: art, music, science, computer, family and consumer
       Sciences)
   •   School counselor
   •   Coaches and physical education teachers
   •   Custodian
   •   Bus driver
   •   Local EMS
   •   Other learning support staff and aides based on the student’s curriculum and activities
   •   Student with food allergy (if age appropriate).

The multi-disciplinary team works to implement written plans outlining each student’s food allergy
management. These written plans help students, their families, school staff, and the student’s healthcare
provider know what is expected of them in implementing effective food allergy management. Important
written plans for effective food allergy management include:

   •   Food Allergy Medical Management Plan – This plan should be part of the Individualized Health
       Care Plan (IHP) and Emergency Care Plan (ECP). This plan is developed by a student’s personal
       healthcare team and family. It outlines the prescribed healthcare regimen and should be signed by
       the student’s board certified allergist, family physician, physician assistant, or certified registered
       nurse practitioner. The Medical Management Plan may include information such as the student’s
       date of diagnosis, current health status, list of equipment and supplies, specific medical orders, and
       emergency contact information.

   •   Emergency Care Plan (ECP) – This plan is based on the information provided in the student’s
       Individualized Health Care Plan and specifically describes how to recognize a food allergy
                                                      9
emergency and what to do when signs or symptoms of these conditions are observed. The school
       nurse usually coordinates the development of the Emergency Plan and the plan should be
       distributed to all school personnel who have responsibility for the student.

   •   Individualized Health Care Plan (IHP) – This plan is required by professional standards of
       nursing practice and uses the nursing process (assessment, diagnosis, planning, implementation,
       and evaluation) to determine a plan of action that meets the healthcare needs of a student during
       the school day. This plan, initiated by the Certified School Nurse, provides written directions for
       school health personnel to follow in meeting the individual student’s healthcare needs. While
       parental/guardian involvement is not required, it is strongly encouraged.

   •    504 Service Agreement – This plan outlines what medical accommodations, educational aids, and
       services a student with food allergies may need in order to have equal access to educational
       opportunities as students without food allergies. The term “504 Service Agreement” is used to
       refer to a plan of services developed under Section 504 of the Rehabilitation Act of 1973.

   •   Individualized Education Program (IEP) with a medical component – This plan is required for
       students who receive special education and related services under the Individuals with Disabilities
       Education Act of 1990. See Section 4 of this guide for more information on these and other
       federal and state laws related to school responsibilities. Education plans vary based on each
       student’s unique needs, but plans for students with food allergies usually include the following
       components:

           o Identity of licensed school nurses and school staff who are trained to administer
             epinephrine auto-injectors
           o Location of the student’s food allergy management supplies
           o Nutritional needs, including provisions for meals and snacks
           o Plans to enable full participation in all school-sponsored activities and field trips
           o Maintenance of confidentiality and the student’s right to privacy

   •   Individualized Transportation Plan (ITP) – This plan provides a standardized approach to
       identify accommodations needed for students while traveling to and from school.

The information in a student’s Individualized Health Care Plan can be used in developing a Section 504
Plan or Individual Education Plan (IEP). The Individualized Health Care Plan is not required by federal
law, but it can be useful in addressing the requirements of federal laws related to school responsibilities
for children with food allergies. The Food Allergy Medical Management Plan is not a substitute for the
education plans required under federal law.

See Section 3 of this guide for samples of Emergency Care Plan (ECP), 504 Service Agreement, and
Individualized Health Care Plan (IHP).

   Individualized
     Meal Plan

   •    Accommodating Students with Disabling Special Dietary Needs - Schools participating in a
       federal Child Nutrition Program (School Lunch, School Breakfast, or After School Snack
       Program) are required to make accommodations for students who are unable to eat the school
       meals because of a disability* that restricts their diet. In order to make modifications or
                                                     10
substitutions to the school meal, schools must have a written Medical Statement on file that is
        signed by a licensed physician. The statement must identify:
            • The student’s special dietary disability
            • An explanation of why the disability restricts the student’s diet
            • The major life activity(ies) affected by the disability
            • The food(s) to be omitted from the student’s diet
            • The food or choice of foods that must be provided as the substitute
        *Only a physician can declare if a student has a disability. Under Section 504 of the
        Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA) of 1990, a "person with
        a disability" means any person who has a physical or mental impairment which substantially limits
        one or more major life activities, has a record of such an impairment, or is regarded as having such
        an impairment. The term "physical or mental impairment" includes many diseases and conditions
        including food anaphylaxis or severe food allergy.

   •    Accommodating Students with Non-Disabling Special Dietary Needs - Schools may, at their
        discretion, make substitutions for students who have a special dietary need, but do not meet the
        definition of disability. Examples include food intolerances or allergies that do not cause life-
        threatening reactions. The decision to accommodate a student’s special dietary need can be
        determined on a case-by-case basis; however, the school should remain consistent with
        accommodating special dietary needs. In order to make modifications or substitutions to the
        school meal, schools must have a written medical statement signed by a recognized medical
        authority** identifying the following:

           •   An identification of the medical or other special dietary condition which restricts the
               student’s diet
           •   The food or foods to be omitted from the student’s diet
           •   The food or choice of foods to be substituted

        **In Pennsylvania, a recognized medical authority includes a physician, physician assistant, and
        nurse practitioner.

        The USDA manual “Accommodating students with Special Dietary needs in the School Nutrition
        Programs” can be accessed at http://www.fns.usda.gov/cnd/guidance/special_dietary_needs.pdf.

       Special School
          Events

Effectively meeting the needs of students with food allergies requires advance planning for special events
such as classroom parties, field trips, and school-sponsored extracurricular activities held before or after
school. With proper planning, students with food allergies can participate fully in all school-related
activities without the presence of a parent/guardian.

Parents/guardians of students with food allergies should be given advance notice of parties and events so
they can decide whether their student should be given the same food as other students or food the parent
will provide. Schools are encouraged to provide guidelines for parties which include non-food prizes.

Students often view a field trip as one of the most interesting, exciting activities of the school year and
students with food allergies must be allowed to have these school-related experiences.

                                                      11
Students’ education plans should carefully describe the plan for coverage and care during school-
sponsored activities which take place while under school jurisdiction during or outside of school hours.

       Disasters and
       Emergencies

Parents/guardians must provide the school with an emergency supply kit so schools are prepared to care
for students with food allergies in the event of natural disasters or emergencies. The emergency supply
kit should contain enough supplies for 72 hours.

      Emotional and
     Social Concerns

The emotional, as well as the physical needs of the student must be respected. A student’s behavior may
be drastically altered by their fears of a reaction. School social workers or guidance counselors should be
available to work with families with food-allergic students. Students with food allergies are “at-risk” for
eating disorders and/or bullying. For example, a student may choose not to eat rather than risk
embarrassment of a reaction in front of a peer.

Students with food allergies must deal with the usual developmental issues of growing up, in addition to
learning to manage their complex disease. Students react differently to having food allergies. They may
be accepting, resentful, open to discussing it, or eager to hide it. Often, the same student will experience
all of these feelings over time. For the most part, students do not want to be singled out or made to feel
different from their peers. Food allergy care tasks can set them apart and make them feel angry or
resentful about their disease. School personnel should be aware of the student’s feelings about having
food allergies and identify ways to ensure that the student is treated the same as others.

Food allergies can also be a focal point for conflict within families. One of the biggest tasks for children
and adolescents is to become increasingly independent from their parents/guardians. However, food
allergies may compromise independence because parents/guardians are concerned about their student’s
ability to perform self-care and take responsibility for it. Parents/guardians, who are ultimately
responsible for their student’s well-being, may be reluctant to allow normal independence in children or
teens who have not been able to take care of themselves properly. This parental concern can lead to
increasing struggles with dependence, oppositional behavior, and rebellion.

Healthcare providers and school personnel must be aware of emotional and behavioral issues
related to food allergy care and management, and refer students and their families for counseling
and support as needed.

                                                     12
Section 2: Addressing Student Needs

This section of the Guide presents the roles and responsibilities of individual school
personnel, parents/guardians, and students with food allergies in managing life-threatening
food allergies.

The action sheets included in this section are useful tools to help ensure effective food
allergy management in schools. The Pennsylvania Departments of Education and Health
encourage the copying and distribution of these actions sheets to school staff members,
parents/guardians and students with food allergies.

                                            13
Actions and Considerations for Administrators on Development of School Policy
•   Develop policies/procedures to minimize potential life-threatening reactions in all classrooms,
    nutrition services/cafeterias, classroom projects, crafts, outdoor activity areas, on school buses, during
    field trips, before-school and after-school activities, and in all instructional areas.
        • Recommend that policies be system-wide.
        • Require the development of appropriate medical plans of care, including an Emergency Care
             Plan (ECP) and Individualized Health Care Plan (IHP), for every student with a life
             threatening allergy.
        • Consider, with school physician and school nurse, standing orders/protocols for licensed
             medical personnel to administer epinephrine auto-injectors to individuals with previously
             undiagnosed allergies.
        • Avoid the use of food products as displays or components of displays in hallways.
        • School options include establishing allergen-free zones, such as a student’s individual
             classroom, allergen-free lunch table(s) or areas in the cafeteria, and food-free zones, such as
             libraries and music rooms.
        • Student’s classroom(s) must be a safe place for all students to learn.
                 • Develop letter for parents/guardians of classmates and substitute teachers. (See samples
                     in Appendix F).
                         • Permission to share this confidential information should be obtained from the
                             parent/guardian of the student with food allergies before sending letter.
                         • Letter should be written on school stationery from the administration, school
                             nurse, or teacher.
        • Consider limiting the presence of animals in school buildings.
        • Enforce policies requiring students and staff to wash hands before and after eating.
        • Field Trips/Transportation in School Vehicles
                 • Establish field trip policy:
                         • Include notification of school nurse in timely manner.
                         • Provision of Emergency Care Plan (ECP) and epinephrine auto-injector to
                             responsible personnel.
                                 • Include location of closest medical facility and 9-1-1 procedures.
                                 • Determine if local ambulance carries epinephrine and have staff trained
                                     to administer.
                                 • Train appropriate staff in administration of epinephrine auto-injectors.
                         • Determination that location of field trip is safe for student with life-threatening
                             allergies.
                         • Consider ways for students to wash hands before and after eating (e.g.
                             provision of hand wipes, etc.)
                         • Invite parent of student with life-threatening allergy to accompany student.
                         • Consider sending a nurse on the field trip.
                         • If meals are being packed by the school or brought by students:
                                 • Avoid meals that may be food allergy related.
                                 • Package meals appropriately to avoid cross-contamination.
        • Enforce policies prohibiting eating on school transportation.
        • Consider special seating arrangements for student.
        • Provide system of communication should an anaphylactic reaction occur.

                                                     14
•   Adapt curriculum, awards, rewards, or prizes by substituting allergen-free food or non-food item(s) in
    rooms where students having an Emergency Care Plan (ECP) may be present. Many schools have
    opted to completely remove food from the curriculum due to the number of students with food
    allergies and the variety of food allergies present within a school or classroom.
        • Constructive Classroom Rewards:
            http://www.cspinet.org/new/pdf/constructive_classroom_rewards.pdf
        • Limit food related to fundraising, birthday celebrations, PTA functions to cafeteria, or other
            designated areas. Incorporate non-allergenic foods or non-food items. See Constructive
            Classroom Rewards above.
•   Establish and communicate cleaning procedures for common areas (i.e., libraries, computer labs,
    buses, music, art room and hallways, etc.). (Appendix C)
        • Develop protocols for appropriate cleaning methods following events held at the school that
            involve food. (Appendix C)
•   Determine, in conjunction with the Certified School Nurse, who should be familiar with the student’s
    medical plans of care.
•   Modify the school’s emergency response plan to include procedures for managing life-threatening
    allergic reactions.
        • Consider development of an emergency response team for each school building:
        • Administration
        • First Aid: School personnel trained in first aid procedures, including administration of
            epinephrine auto-injectors.
        • Communication: School personnel responsible for maintaining communication between scene
            and office.
        • Crowd control: School personnel responsible for directing ambulance crew to the scene and
            managing other students/school personnel.
        • Develop emergency procedures including:
        • Assess emergency at hand and activate emergency response team (including the school nurse
            and administration).
        • Administer the epinephrine auto-injector.
        • Notify Emergency Medical Services.
        • Notify the parent/guardians.
        • Notify student’s primary care provider and/or allergy specialist.
        • Manage crowd control.
        • NOTE: Some of these steps will need to be performed simultaneously.
        • Develop protocols for student’s re-entry to school following a life-threatening allergic
            reaction.
        • Provide emergency communication devices (two-way radio, intercom, walkie-talkie, cell
            phone) for all school activities, including transportation that involve a student with food
            allergies.
        • Ensure contingency plans are in place to continue care of the student in case of a substitute
            nurse, teacher, or nutrition service personnel.
        • Ensure contingency plans are in place when there is no nurse available.
        • Educate all school personnel on life-threatening allergic conditions and the school’s procedure
            for managing a life-threatening allergic reaction. (See more detail in next section).
        • Train school personnel on the administration of epinephrine auto-injectors. (See more detail in
            next section).
        • Include local Emergency Management Services in planning.
        • Determine if local ambulance has epinephrine auto-injectors available and staff with approval
            to administer.
                                                    15
•    Determine unlocked location where epinephrine auto-injectors will be stored for quick
            response and accessibility, if not carried by student.
        • Adhere to Occupational Safety and Health Administration (OSHA) and Universal Precaution
            Guidelines for disposal of epinephrine auto-injectors after use.
        • Ensure school district policy includes authorization for students to self-carry and administer
            epinephrine auto-injectors.
•   Arrange the schedule to allow for a fulltime nurse in every school building where a student with food
    allergies attends.
•   Consider assigning the student to a classroom where the teacher is trained to administer an
    epinephrine auto-injector and/or ensure assigned teacher is trained to administer epinephrine auto-
    injector.
•   In the event of a fatal allergic reaction:
        • Implement the school’s crisis plan for the death of a student.
        • In addition to counselors to assist staff and students, consider providing adults with knowledge
            of food allergies to answer questions.
        • Resources on dealing with the death of a student are available at:
        • The Food Allergy & Anaphylaxis Network (FAAN), www.foodallergy.org
        • Pennsylvania All-Hazards Planning Toolkit for Schools,
            http://www.portal.state.pa.us/portal/server.pt/community/plans,_guides_and_presentations/462
            5/all-hazards_school_safety_planning_toolkit_(pdf)/541340

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Actions and Resources for Developing Training for School Staff
•   Ensure training for nutrition service personnel and school health staff is provided.
•   Include substitute teachers, nurses, and nutrition service personnel in training opportunities.
•   Teach all faculty and staff about the signs and symptoms of possible anaphylaxis. This training should
    include:
        • How to recognize symptoms of an allergic reaction.
        • Review of high-risk areas.
        • Steps to take to prevent exposure to allergens.
        • How to respond to an emergency.
                • Recognize a life-threatening reaction and activate emergency medical services (Call 9-
                   1-1).
                • Activate building emergency response team.
                • Talk reassuringly to the student and keep them informed.
        • How to respond to a student with a known allergy as well as a student with previously
           unknown allergy.
•   Train school personnel on the administration of epinephrine auto-injectors.
        • Encourage all school personnel to volunteer for this training.
        • Consider having school staff trained as instructors for the American Heart Association or
           American Red Cross and use their training modules.
        • Recommend an annual skills check.
        • Determine location of list of trained personnel for quick response.
•   Conduct a medical emergency response drill twice a year. The recommended interval is at the
    beginning of school year and just after mid-year break.
•   Resources for Training
        • Special Dietary Needs webpage created by the Pennsylvania Department of Education,
           Division of Food and Nutrition (DFN): This webpage contains training resources, including
           webinars presented by PDE/DOH and National School Boards Association.
           http://www.portal.state.pa.us/portal/server.pt/community/national_school_lunch/7487/special_
           dietary_needs_in_school_nutrition_programs-_resources/509222.
        • Project PA, a collaboration between PDE, DFN, and Penn State University, has a School
           Nutrition Training Module on Serving Students with Special Dietary Needs available at
           http://nutr88.hhdev.psu.edu/smi/login/index.php.
        • DOH Learning Management System (LMS) School Track Online training, eligible for Act 48
           of 1999 Continuing Education for Professional School Personnel and Act 58 of 2006
           Continuing Education for RNs. To register as a user or to access your account for available
           courses, go to www.paprepared.net.

                                                    17
Actions for Principals

•   Participate in developing and implementing school policy related to food allergy management at
    school.
•   Ensure sufficient allocation of resources to manage students with food allergies in your school.
•   Ensure the development and implementation of a system that keeps school health and nutrition
    services informed of the pending enrollment of students with food allergies and any related enrollment
    changes that may occur throughout the school year.
•   Promote a supportive learning environment for students with food allergies. Treat these students the
    same as other students, except to be responsive to medical needs as outlined in the student’s written
    medical plans of care.
•   Identify all staff members who have responsibility for students with food allergies.
•   Meet at least annually with the school health team. Arrange and attend a meeting of the school health
    team members (student, family, school nurse, 504/IEP coordinator, teacher(s), and other staff
    members who have primary responsibility for the student) before the school year starts, or when the
    child is newly diagnosed, to discuss medical accommodations, educational aids, and services related
    to the student’s needs.
•   Support food allergy management training for the school nurse and other staff responsible for students
    with food allergies.
•   Alert all school-related staff members who teach or supervise a student with food allergies. Ensure
    that they, including the bus driver and coaches, are familiar with the accommodations and emergency
    procedures outlined in the student’s medical plans of care.
•   Alert all substitute personnel. Ensure that they are aware of the needs and emergency procedures for
    students with food allergies.
•   Respect the student’s confidentiality and right to privacy.
•   Help establish on-campus and off-campus emergency protocols.
•   Facilitate and support ongoing communication between parents/guardians of students with food
    allergies and school staff.
•   Learn about food allergy management by reviewing the information and resources presented in this
    guide.
•   Be able to recognize and support response to signs and symptoms of a life threatening allergic reaction
    in accordance with the student’s written emergency plans. This includes knowing when and how to
    contact the school nurse.
•   Understand the federal and state laws that apply to students with food allergies. See Section 4 of this
    guide for more information.

                                                    18
Actions for School Nurses
School nurses coordinate the provision of healthcare services for a student with food allergies at school
and at school-related activities. When notified that a student with food allergies is enrolled in the school,
annually, or more often as necessary, the school nurse:
        • Initiates the appropriate medical plans of care (IHP, 504 Service Plan, or IEP with a medical
           component). Encourage parent/guardian involvement in the development of these plans, where
           appropriate. The plan shall include:
               • Student name
               • Specific offending allergens
               • Warning signs of reactions
               • Emergency treatment
                       • Name of persons/positions trained in administering the epinephrine
                           auto-injector
                               • Establish contingency plan should student be unable to self-administer
                                   or primary person is absent
                       • Where the medication is stored (or carried by student)
                       • Procedure to monitor the expiration date
               • Risk reduction and emergency response at the following times:
                       • Travel to and from school
                       • School day
                       • Before and after school programs
                       • Field trips
                       • Emergency situations (e.g. evacuations, lockdowns or shelter-in-place)
        • Initiates an Emergency Care Plan (ECP) for all identified students.
               • Should be with the student at all times as well as appropriate adults.
               • The plan shall include (see above)
               • Should be signed by the Certified School Nurse.
               • See Section 3 of this document for a sample ECP.
        • Determine competency for student to carry and self-administer epinephrine auto-injector.
        • Following a moderate to severe reaction:
               • Obtain as much accurate information as possible about the allergic reaction, including
                   those who witnessed the event and those who provided medical intervention.
               • Meet with parents/guardians and student to discuss event and concerns.
                       • Discuss student’s feelings about returning to school.
                       • Check in with student on a daily basis to alleviate anxiety.
                       • If an anxiety response is prolonged, collaborate with parents/guardians and the
                           student’s medical provider to determine interventions.
                               • Consider possible referral to Student Assistance Team.
               • Meet with school staff to discuss the event and dispel any rumors.
               • Provide factual information.
               • This may be discussed with the parent/guardian, but information that does not identify
                   the student may be shared with the school community without parental/guardian
                   permission (e.g., a letter from the principal to parents and teachers).
               • Information provided to students shall be age appropriate.

                                                     19
•    If the reaction is thought to be from a food provided by the school, request assistance
            of the Nutrition Service Director to ascertain what potential food item was
            served/consumed.
        • Review food labels with Nutrition Service Director and staff.
        • Review the student’s medical plans of care and amend as necessary.
•   Facilitate the initial school health team meeting to discuss the implementation of the IHP and
    participate in the development of the student’s education plan. The school nurse will help
    monitor compliance with these plans and facilitate follow-up meetings of the school health
    team to discuss concerns, receive updates, and evaluate the need for changes to the student’s
    plan.
•   Obtain materials and medical supplies necessary from the parent/guardian and arrange a
    system for notifying the student or parents/guardian when supplies need to be replenished.
•   Provide food allergy education resources for the student, family, and school staff, which can
    include sharing and reviewing sections of this guide. Help ensure that individuals mentioned
    in education plans know their roles in supporting food allergy management and know when
    and where to seek help. School Nurses can contact the Department of Health for information.
•   Participate in food allergy management training provided by healthcare professionals and
    organizations with expertise in food allergies to attain or enhance knowledge about current
    standards of care.
        • Practice universal precautions and infection control procedures during all student
            encounters.
•   Maintain accurate documentation of contacts with the student and family members,
    communications with the student’s healthcare provider, and any direct care given, including
    medication administration.
•   Collaborate with other school personnel and partner agencies, such as food service staff or
    school transportation services, to support food allergy management, as necessary.
•   With parental permission, act as a liaison between the school and the student’s healthcare
    provider regarding the student’s self management at school.
        • Communicate to parents/guardian any concerns about the student’s food allergy.
•   Promote and encourage independence and self-care consistent with the student’s ability, skill,
    maturity, and developmental level.
•   Respect the student’s confidentiality and right to privacy.
•   Act as an advocate for students to help them meet their food allergy healthcare needs.
•   Assist the classroom teacher with developing a plan for substitute teachers to meet student
    needs according to care plans.
        • Be knowledgeable about federal, state, and local laws and regulations that pertain to
            managing food allergies at school.

                                             20
The Pennsylvania Public School Code (PSC) of 1949 defines a school nurse as a
         licensed registered nurse who is properly certificated by the Pennsylvania
         Department of Education as a school nurse and who is employed by a school
         district or joint school board as a school nurse, or is employed in providing school
nurse services to children of school age by a county health unit or department or board of
health in any municipality with which a school district or joint school board has contracted
for school health services pursuant to the provisions of 1411 of PSC.

Under the Pennsylvania Nurse Practice Act, there is no provision for a registered nurse
(RN) to delegate nursing tasks. However, according to the Pennsylvania Department of
State, Board of Nursing, RNs may train unlicensed individuals to assist with the
administration of asthma inhalers and epinephrine auto-injectors. Supplemental licensed
nurses who are not certified school nurses must work under the direction of the school
nurse and cannot be assigned a caseload.

A licensed nurse must have an order for medications. Without an order, licensed nurses
administering medication are diagnosing and prescribing treatment, which is outside of
nursing practice parameters and is within the practice of medicine defined by the Medical
Practice Act of 1985.

See Section 4 of this guide for more information about state and federal laws related to the
                               care of students with diabetes.

                                             21
Actions for Teachers
•  With approval from the parents/guardians of the student with life-threatening food allergies, notify
   parents/guardians of students in the class that there is a student with a life-threatening food allergy and
   ways that the parent/guardians can help reduce the risk of exposure to an allergen. (See Appendix F:
   Sample letter for classmates and parents).
       • Include a cut off portion for parents of classmates to return to the school as proof of receipt of
           the information.
       • Coordinate with parents/guardians on providing a lesson plan about food allergies for the class
           and discuss anaphylaxis in age appropriate terms, with student’s permission.
       • Educate classmates to avoid endangering, isolating, stigmatizing, or harassing students with
           food allergies.
       • Work with the school nurse to educate other parents/guardians about the presence and needs of
           the student with life-threatening allergies. Enlist their help in keeping certain foods out of the
           classroom.
 • Determine special seating arrangements in the classroom, if necessary.
 • Be aware of cleaning protocols and allowable cleaning solutions for the classroom.
 • Receive the Emergency Care Plan (ECP) of any students(s) in their classroom with life-threatening
   allergies.
       • Keep ECP with photo (if available) accessible in classroom or with lesson plan.
       • Be sure volunteers, student teachers, aides, specialists, and substitute teachers, in the
           classroom throughout the school year, are informed of the student’s food allergies and
           necessary safeguards.
       • Leave information in an organized, prominent, and accessible format for substitute teachers.
• Request that the classroom has a functioning intercom, walkie-talkie or other communication device
   for communication with the school nurse.
• Participate in a team meeting for the student and in-service training regarding:
       • Allergens that cause life-threatening reactions and accidental exposures to allergens.
       • How to recognize symptoms of a life-threatening allergic reaction.
       • Steps to manage an emergency.
       • How to administer an epinephrine auto-injector.
• Be aware of how the student is being treated; enforce school rules about bullying and threats.
• Inform parents/guardians of student(s) with life-threatening food allergy of any school events where
   food will be served.
       • Consider having the parents/guardians provide classroom snacks for their student. These
           snacks should be kept in a separate snack box.
• If not covered by school policy, establish classroom rules to decrease the risk of exposure for the food
   allergy student.
       • Teach all students proper hand-washing techniques and consider washing their hands before
           and after eating.
       • Use non-food items for rewards instead of candy or other food.
       • Consider a non-food treat for all parties/celebrations. If food treats are provided, recommend
           they be pre-packaged and labeled to assist in identifying allergens.
       • Prohibit sharing or trading food in the classroom.
       • Classroom animals can be problematic on many levels. If an animal is present in the
           classroom, special attention must be paid to the ingredients in their food as many animal foods
           contain peanuts or other common allergens.
       • Understand that classroom project materials containing the allergen may not be used.
                                                     22
•   Never question or hesitate to act if a student reports signs of an allergic reaction.
•   Be able to recognize and support response to signs and symptoms of an anaphylactic reaction in
    accordance with the student’s written emergency plans. This includes knowing when and how to
    contact the school nurse.
•   Provide a supportive environment for the student to manage food allergies effectively and safely at
    school.
•   Provide classroom accommodations for the student with food allergies, as indicated in the student’s
    medical plan of care.
•   Notify the parents/guardian in advance of changes in the school schedule, such as class parties, field
    trips, and other special events.
•   Communicate with the school nurse or parent/guardian regarding any concerns about the student.
•   Learn about food allergies by reviewing the information and resources presented in this guide and
    discussing effective food allergy management with the school nurse.
•   Respect the student’s confidentiality and right to privacy.
•   Treat the student with food allergies the same as other students, except to be responsive to medical
    needs as outlined in the student’s written care plans.
•   Younger students are more likely to put their hands and/or items in their mouths and may require
    food-free or allergen-free classrooms. Consider having everyone wash their hands before entering the
    classroom and after eating.
•   All concerns from students with a food allergy are to be taken seriously.

.

                                                    23
Actions for Counselors

•   Work with school staff to promote a supportive learning environment.
•   Help to ensure that students with food allergies are treated the same as other students, except to be
    responsive to medical needs as outlined in the student’s written care plans.
•   Provide input to the school health team when requested.
•   Communicate with the school nurse regarding any concerns about the student.
•   Be aware and be prepared to respond to the emotional needs of the student. Students react differently
    to having food allergies. Some are accepting and open to discussing it; others are resentful and may
    attempt to hide it. Often, a single child will experience both kinds of feelings. Be aware of the
    student’s feelings and identify ways to ensure the student is treated the same as other students.
•   Be aware that some students may not wish to share information about their food allergies with other
    students or school staff, particularly if it makes them feel different from others.
•   Promote and encourage independence and self-care consistent with the student’s ability, skill, maturity
    and developmental level.
•   Respect the student’s confidentiality and right to privacy.
•   Recognize that students with chronic illnesses may rebel by discontinuing all or part of their medical
    regimen.
•   All concerns from students with a food allergy are to be taken seriously.

                                                    24
Actions for Custodians

•   Ensure that cleaners are properly labeled and storage areas for cleaning supplies are identified.
•   Avoid cross-contamination of foods by wiping down eating surfaces with an appropriate cleaner
    before and after eating. (See Appendix C).
•   Tables should also be washed with an appropriate cleaner in the morning if an after-school event has
    been held in the cafeteria the night before.
•   Never question or hesitate to act if a student reports signs of an allergic reaction.

                                                   25
Actions for Coaches, Physical Education Instructors, Playground Staff and Other
Onsite Persons in Charge of Conducting After School Activities

•   Participate in team meetings to discuss implementation of student’s plans of care.
•   Conduct the activities in accordance with all school policies and procedures regarding life threatening
    allergies.
•   Keep a copy of the Emergency Care Plan, including a photo of the student.
•   Make certain that a emergency communication device (e.g. walkie-talkie, intercom, cell phone) is
    always available.
•   Participate in training to administer epinephrine auto-injectors.
         • At least one person should be present at each activity who is trained in administration of this
             device.
•   Know local Emergency Medical Services procedures.
•   Identify the staff responsible for keeping the first aid kit.
•   If for safety reasons, medical alert identification needs to be removed during specific activities,
    remind the student to replace this identification immediately after the activity is completed.
•   Provide input to the student’s school health team as needed.
•   Communicate with the school nurse regarding any concerns about the student.
•   Provide information for substitute instructors that communicate the daily needs of the student and the
    written emergency care plan.
•   Respect the student’s confidentiality & right to privacy.
•   Treat the student with food allergies the same as other students, except to be responsive to medical
    needs as outlined in the student’s written care plans.
•   All concerns from students with a food allergy are to be taken seriously.
•   Be able to recognize and support response to signs and symptoms of an anaphylactic reaction in
    accordance with the student’s written emergency plans. This includes knowing when and how to
    contact the school nurse or EMS.
•   Learn about food allergies by reviewing the information and resources presented in this guide and
    discussing effective food allergy management with the school nurse.
•   Younger students are more likely to put their hands and/or items in their mouths and may require
    food-free or allergen-free classrooms. Consider having everyone wash their hands before entering the
    classroom and after eating.
•   Coaches and after-school activities coordinators should particularly be aware of field trip/off-school
    site procedures for outings and travel.

                                                    26
Actions for Food Service Managers and Lunchroom Staff

•   Provide a representative for team meetings to discuss implementation of student’s plans of care.
•   Work with the school nurse in identifying students with life-threatening allergies.
•   Obtain Medical Plan of Care form and maintain file in cafeteria office.
        • Plan appropriate substitutions or modifications for meals served to students with life-
            threatening food allergies.
•   If Point of Sale system is used, include allergy alerts and picture of the student.
•   Post student’s Emergency Care Plan in readily accessible spot.
•   Evaluate the need for special seating arrangements, such as an allergen-free table, zone, etc.
•   Follow appropriate cleaning and sanitation techniques
        • Avoid cross-contamination of foods by wiping down eating and preparation surfaces/utensils
            with an appropriate cleaner before, during and after preparation and eating. (See Appendix C).
                 • Common examples of cross-contamination:
                        • Lifting peanut butter cookies with a spatula and then using the same spatula to
                            lift sugar cookies.
                        • Using a knife to make peanut butter sandwiches, wiping the knife and then
                            using the same knife to spread mustard on the cheese sandwich of a peanut
                            allergic student.
        • Tables should also be washed with an appropriate cleaner in the morning if an after-school
            event has been held in the cafeteria the night before.
        • Wash preparation areas, work surface, utensils, pots and pans with hot soapy water. Soap
            denatures the protein that causes the allergy.
        • Consider using a color-coded cutting board system to minimize cross-contamination.
•   Reinforce hand-washing before and after eating for all students and staff.
•   Read all food labels and recheck routinely for potential food allergens.
        • Be prepared to discuss: menus (breakfast, lunch and after school snack); a la carte items;
            vending machines; recipes; food products and ingredients; food handling practices; cleaning
            and sanitation practices; and responsibility of various staff (or additional contract employees at
            individual schools).
        • Prepared food ingredient lists used in food production and service. Be aware that the
            manufacturer may make substitutions to products without notification.
        • Maintain food labels from each food served to a student with life-threatening food allergies for
            at least 24 hours following service in case of a delayed anaphylactic reaction.
        • See The Food and Allergy Anaphylaxis Network website for more information about reading
            food labels to avoid potential allergens at
            http://www.foodallergy.org/section/shoppingselecting-safe-foods.
•   Maintain contact information for manufacturers of food products (Consumer Hotline), vendors and
    purveyors.
        • Ask specific questions. (e.g. Does your product include peanuts? Is there a risk of cross-
            contamination with peanuts in your food manufacturing process?)
•   Establish and enforce procedures for sound food handling practices to avoid cross-contamination,
    including frequent hand washing.
•   Train cafeteria staff and monitors:
        • Proper cleaning techniques and solutions (See Appendix C) for tables, chairs, and food
            preparation surfaces.
        • Reading of product food labels and recognition of food allergens.

                                                     27
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